1 of 10 State of Florida

Department of Business and Professional Regulation Board of Accountancy

Application for Licensure by Endorsement/Transfer of Examination Grades Form # DBPR CPA 3

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule: 61H1-29.003

APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your application to ensure faster processing.

Please mail your completed application, documentation and required fee(s) to: Department of Business and Professional Regulation

2601 Blair Stone Rd Tallahassee, FL 32399

The State of Florida offers four methods by which an individual who has passed the CPA examination in another State may obtain a Florida CPA license:

1. Transferring Examination Grades, Section 473.308(7) (a) 1, F.S.2. Endorsement- Licensed in Another State, Section 473.308(7) (b) 1.a., F.S.3. Endorsement- Licensed in Another State at least 10 years Section 473.308(7) (b) 1.c., F.S.4. Endorsement- Licensed in Another State with at least five (5) years of experience, Section

473.308(8), F.S.

Requirements for Transferring Examination Grades • Applicant is not licensed and has not been licensed in another state or territory.• An individual must have passed all four parts of the A.I.C.P.A. Uniform CPA Examination, with agrade of at least 75 on all four parts (or passed the IQEX with a grade of 75 or better for Approved Chartered Accountants.) • Applicant must have a bachelor's degree from an accredited college or university and 150semester hours or 225 quarter hours of college education, unless one is using the provisions of the unaccredited institutions rule, as explained below, with a concentration in accounting and business. • One year of work experience is required if application for licensure is made after December 31,2008. • If it has been two or more years since you passed the CPA Exam, then 80 hours of CPE with atleast 20 hours in accounting/auditing subjects are required. No more than 20 hours are allowed in behavioral subject. The time period for these hours is the 24 months immediately prior to when the Board office receives the application.

APPLICATION REQUIREMENTS ALL License Applicants must submit:

Fees: • $300• Make check payable to the Florida Department of Business and Professional Regulation.

Official school transcripts to verify education requirement. Do not submit copies of transcripts. Supporting legal documentation, if necessary. See Section IV of Instructions. Send the Authorization for Interstate Exchange of Examination and Licensure Information Form # DBPR CPA 5012-1 (included in this application packet) to each state board of accountancy in which you previously sat for the CPA exam or held a license in another state along with any processing fees they may require. This form is required even if no exam credit was earned in prior attempts. Completed Certification of Work Experience Form # DBPR CPA 32 (included in this application

packet).

Any applicant who has passed the CPA Exam two years or more prior to application in Florida must submit: Completed CPE Reporting Form # DBPR CPA 41 (included in this application packet).

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For more information regarding continuing professional education (CPE) requirements please refer to Chapter 61H1-33 of the Florida Administrative Code at https://www.flrules.org/gateway/ChapterHome.asp?Chapter=61H1-33.

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule: 61H1-29.003

Requirements for Endorsement • Applicant holds a valid license to practice public accounting issued by another state or territory ofthe United States, where the criteria for issuance of such license is substantially equivalent to the licensure criteria that existed in this state at the time the license was issued; OR • Applicant holds a valid license to practice public accounting issued by another state or territory ofthe United States; and

o Passed all four parts of the A.I.C.P.A. Uniform CPA Examination, with a grade of at least75 on all four parts (or passed the IQEX with a grade of 75 or better for ApprovedChartered Accountants.)

o Applicant has a bachelor's degree from an accredited college or university and 150semester hours or 225 quarter hours of college education, unless one is using theprovisions of the unaccredited institutions rule, as explained below, with a concentrationin accounting and business.

o Applicant has one year of work experience, if application for licensure is made afterDecember 31, 2008.

• If it has been two or more years since you passed the CPA Exam, then 80 hours of CPE with atleast 20 hours in accounting/auditing subjects are required. No more than 20 hours are allowed in the behavioral subjects. The time period for these hours is the 24 months immediately prior to when the Board office receives the application. • If an applicant for endorsement has been licensed in another state at least 10 years as a certifiedpublic accountant, the Board of Accountancy will waive the educational requirements and work experience. For more information about this waiver please refer to Section 473.308(7) (c), Florida Statues. • If an applicant for endorsement has at least five (5) years of public, industry, academia, orgovernmental accounting experience, after licensure, as a CPA or approved Chartered Accountant, the Board of Accountancy will waive the educational requirements which are in excess of a baccalaureate degree. For more information about this waiver please refer to section 473.308(8), Florida Statutes.

Accreditation The Board accepts degrees from schools accredited by the following associations: Middle States Association of Colleges and Secondary Schools, New England Association of Schools and Colleges, Higher Learning Commission, Northwest Commission on Colleges and Universities, Southern Association of Colleges and Schools, Western Association of Schools and Colleges, Association to Advance Collegiate Schools of Business (AACSB), Association of Independent Colleges and Schools regulated by the Commission for Independent Education and exempted from licensure by the CIE under the provisions of Section 246.085, F.S. and Canadian, Australian, Mexican, Irish, New Zealand and Hong Kong academic accounting programs approved by the provincial educational bodies or the equivalent educational accreditation body for that country. If you have graduated from a school or college which is not accredited by the above mentioned means, then you must use the provisions of Rule 61H1-27.001 (5), F.A.C. (see below). Applicants Who Have Graduated from Non-Accredited Schools (Rule 61H1-27.001 (5), F.A.C.) Applicants who have graduated from a non-accredited school may still qualify for CPA licensure. The applicant must complete at least 15 semester or 22 quarter hours of graduate classes, of which nine (9) semester or 13 quarter hours must be accounting and three (3) semester or four (4) quarter hours of tax. These courses cannot duplicate other courses, which the applicant has taken. The applicant must complete the graduate school courses to validate the non-accredited degree. The applicant must also meet all other educational requirements for CPA licensure applicants. An evaluation of the unaccredited transcripts must be completed by an evaluation service, which has been approved by the Board (see Board Approval Evaluation Services attached).

For more information regarding the educational requirements necessary for CPA licensure please refer to Chapter 61H1-27 of the Florida Administrative Code at https://www.flrules.org/gateway/ChapterHome.asp?Chapter=61H1-27.

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule: 61H1-29.003, F.A.C

3 of 10 State of Florida

Department of Business and Professional Regulation Board of Accountancy

Application for Licensure by Endorsement/Transfer of Examination Grades Form # DBPR CPA 3

If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395. For additional information see the Instructions at the end of this application.

Section II – Applicant Information APPLICANT INFORMATION

Social Security Number*

FULL LEGAL NAME Last Name First Middle

Birth Date (MM/DD/YYYY) / /

Gender D Male D Female

MAILING ADDRESS Street Address or P.O. Box

City State Zip Code (+4 optional)

County (if Florida address) Country

CONTACT INFORMATION Phone Number Fax Number

Email Address

DOMICILE AND EXAM INFORMATION Date domiciled in Florida

/ / Date passed Uniform CPA Examination

/ /

* The disclosure of your social security number is mandatory on all professional and occupational license applications,is solicited by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of Business and Professional Regulation pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by § 559.79(1), Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.

METHOD OF QUALIFICATION Check the provision under which you are applying: 473.308(7) (a) 1.Transferring Examination Grades (Has never held a license in another state) 473.308(7)(b)1.a. Valid License to Practice in Another State at least one year of experience 473.308(7)(b)1.c. Valid License to Practice in Another State at least 10 years 473.308(8) Valid License to Practice in Another State at least 5 years of experience

Section I – Method of Qualification [0101/1031]

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule 61H1-29.003, F.A.C.

4 of 10 Section II – Applicant Information continued

CURRENT/PRIOR LICENSE INFORMATION If you currently hold or have previously held a business or professional license/registration in Florida or elsewhere, please list each one below (attach additional copies of this page as necessary): 1. License/Registration Type State Date (From)

/ / Date (To)

/ / License Number Name Used

2. License/Registration Type State Date (From) / /

Date (To) / /

License Number Name Used

3. License/Registration Type State Date (From) / /

Date (To) / /

License Number Name Used

PRIOR NAME INFORMATION Have you used, been known as, or are currently known by another name (example - maiden name, nickname) or alias other than the name signed to the application? Yes No If your answer is yes, state name or names used below: Last Name First Middle Title Suffix

Last Name First Middle Title Suffix

Last Name First Middle Title Suffix

Section III – Education Information EDUCATION INFORMATION

List the names and addresses of each college or university attended.

1. Institution Date (From) / /

Date (To) / /

Address Graduate Yes No

Degree

City State Zip code

2. Institution Date (From) / /

Date (To) / /

Address Graduate Yes No

Degree

City State Zip code

3. Institution Date (From) / /

Date (To) / /

Address Graduate Yes No

Degree

City State Zip code

4. Institution Date (From) / /

Date (To) / /

Address Graduate Yes No

Degree

City State Zip code

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule: 61H1-29.003, F.A.C.

5 of 10 Section IV (a) – Background Questions

BACKGROUND QUESTIONS 1. Yes

(If yes, please complete

Section IV (b))

No Have you ever been convicted or found guilty of, or entered a plea of nolo contendere or guilty to, regardless of adjudication, a crime in any jurisdiction, or are you currently under criminal investigation? This question applies to any criminal violation of the laws of any municipality, county, state or nation, including felony, misdemeanor and traffic offenses (but not parking, speeding, inspection, or traffic signal violations), without regard to whether you were placed on probation, had adjudication withheld, were paroled, or pardoned. If you intend to answer “NO” because you believe those records have been expunged or sealed by court order pursuant to Section 943.0585 or 943.059, Florida Statutes, or applicable law of another state, you are responsible for verifying the expungement or sealing prior to answering "NO." YOUR ANSWER TO THIS QUESTION MAY BE CHECKED AGAINST LOCAL, STATE AND FEDERAL RECORDS. FAILURE TO ANSWER THIS QUESTION ACCURATELY MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE. IF YOU DO NOT FULLY UNDERSTAND THIS QUESTION, CONSULT WITH AN ATTORNEY OR CONTACT THE DEPARTMENT.

2. Yes (If yes, please

complete Section IV (c))

No Has any judgment or decree of a court been entered against you in this or any other state, province, district, territory, possession or nation, related to the practice or profession for which you are applying, or is there any such case or investigation pending?

3. Yes(If yes, please

complete Section IV (c))

No Have you ever had an application for registration, certification, or licensure in Florida or in any other jurisdiction denied, or is there now pending a proceeding or investigation to deny such an application?

4. Yes(If yes, please

complete Section IV (c))

No Has any license, registration, or permit to practice any regulated profession, occupation, vocation, or business been revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined in Florida or in any other jurisdiction, or is any such proceeding or investigation now pending?

5. Yes(If yes, please

complete Section IV (c))

No Have you ever held yourself out or practiced as a Certified Public Accountant in the geographical boundaries of the State of Florida?

If you answered “YES” to any question in questions 1 – 5 above, please refer to Section IV of Instructions for detailed instructions on providing complete explanations, including requirements for submitting supporting legal documents. Please complete Section IV (b) for your response to question 1, and complete Section IV (c) for your response to questions 2, 3, 4, and 5. If you have more offenses to document in Section IV (b), attach additional pages as necessary. Section IV (b) – Explanation(s) for Background Question 1

EXPLANATION Offense

County State

Penalty/Disposition

Date of Offense (MM/DD/YYYY) / /

Have all sanctions been satisfied? Yes No

Description

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule 61H1-29.003, F.A.C.

6 of 10 Section IV (b) – Explanation(s) for Background Question 1 – continued

EXPLANATION Offense

County State

Penalty/Disposition

Date of Offense (MM/DD/YYYY) Have all sanctions been satisfied? / / Yes No

Description

EXPLANATION Offense

County State

Penalty/Disposition

Date of Offense (MM/DD/YYYY) / /

Have all sanctions been satisfied? Yes No

Description

Section IV (c) – Explanation(s) for Background Questions 2, 3, 4 and 5 EXPLANATION

State/Jurisdiction: Application Type/License Number:

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule 61H1-29.003, F.A.C.

7 of 10 Section IV (c) – Explanation(s) for Background Questions 2, 3, 4 and 5– continued

EXPLANATION State/Jurisdiction: Application Type/License Number:

Section V – Affirmation by Written Declaration AFFIRMATION BY WRITTEN DECLARATION

I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license.

Signature: Date:

Print Name:

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule: 61H1-29.003, F.A.C.

8 of 10 Instructions

If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

1) Requirements for Transferring Examination Gradesa) Applicant is not licensed and has not been licensed in another state or territory.b) An individual must have passed all four parts of the A.I.C.P.A. Uniform CPA Examination, with a

grade of at least 75 on all four parts (or passed the IQEX with a grade of 75 or better forApproved Chartered Accountants.)

c) Applicant must have a bachelor's degree from an accredited college or university and 150semester hours or 225 quarter hours of college education, unless one is using the provisions ofthe unaccredited institutions rule, as explained below, with a concentration in accounting andbusiness.

d) One year of work experience is required if application for licensure is made after December 31,2008.

e) If it has been two or more years since you passed the CPA Exam, then 80 hours of CPE with atleast 20 hours in accounting/auditing subjects, and no more than 20 hours in the behavioralcategory is also required. The time period for these hours is the 24 months immediately prior towhen the Board office receives the application.

2) Requirements for Endorsementa) Applicant holds a valid license to practice public accounting issued by another state or territory of

the United States, where the criteria for issuance of such license is substantially equivalent to thelicensure criteria that existed in this state at the time the license was issued; OR

b) Applicant holds a valid license to practice public accounting issued by another state or territory ofthe United States; andi) Passed all four parts of the A.I.C.P.A. Uniform CPA Examination, with a grade of at least 75

on all four parts (or passed the IQEX with a grade of 75 or better for Approved CharteredAccountants.)

ii) Applicant has a bachelor's degree from an accredited college or university and 150 semesterhours or 225 quarter hours of college education, unless one is using the provisions of theunaccredited institutions rule, as explained below, with a concentration in accounting andbusiness.

iii) Applicant has one year of work experience, if application for licensure is made afterDecember 31, 2008.

c) If it has been two or more years since you passed the CPA Exam, then 80 hours of CPE with atleast 20 hours in accounting/auditing subjects, and no more than 20 hours in the behavioralcategory is also required. The time period for these hours is the 24 months immediately prior towhen the Board office receives the application.

d) If an applicant for endorsement has been licensed at least 10 years in another state as a certified public accountant the Board of Accountancy will waive the educational requirements and work experience. For more information about this waiver please refer to Section 473.308(7) (c), Florida Statute.

e) If an applicant for endorsement has at least five (5) years of public, industry, academia, or governmental accounting experience, after licensure, as a CPA or approved Chartered Accountant under the supervision of an active CPA or approved Chartered Accountant, the Board of Accountancy will waive the educational requirements which are in excess of a baccalaureate degree. For more information about this waiver please refer to Section 473.308(8), Florida Statutes.

3) Additional Informationa) For more information regarding the educational requirements necessary for CPA licensure please

refer to Chapter 61H1-27 of the Florida Administrative Code athttps://www.flrules.org/gateway/ChapterHome.asp?Chapter=61H1-27.

b) For more information regarding continuing professional education (CPE) requirements pleaserefer to Chapter 61H1-33 of the Florida Administrative Code athttps://www.flrules.org/gateway/ChapterHome.asp?Chapter=61H1-33.

4) Application Instructions by sectiona) Section I- Method of Qualification

i) Select the method of qualification under which you qualify for licensure.

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule 61H1-29.003, F.A.C.

9 of 10 b) Section II- Applicant Personal Information

i) Fill out each section completely. A Social Security number is required in order to apply forany individual license within the Department of Business and Professional Regulation.

ii) In the Full Legal Name section, applicants must use the name as it appears on his or herSocial Security card. Do not use any nicknames, aliases, or initials.

iii) Provide your mailing address. This will be used for sending correspondence regarding yourapplication and license.

iv) Provide a valid phone number and email address. Contact information is often used to quicklyresolve questions with applications by telephone call or email. If contact information is notprovided, questions regarding applications will be mailed to the applicant’s mailing addressand may take longer to resolve.

v) Applicants must provide information on current or prior licenses held in Florida or any otherstate, territory, or jurisdiction of the United States or in any foreign national jurisdiction.

vi) Applicants must provide information on any prior names or aliases used by applicant. If thename on supporting documentation does not match the applicant’s legal name, the alias usedin the supporting documentation must be provided in this section. Failure to do so will resultin a deficient application.

c) Section III- Education Informationi) Provide the name and address of each college or university that you have attended.ii) Provide the dates of attendance and whether or not you graduated from that college or

university.iii) If you graduated from that college or university, provide the degree that was conferred upon

graduation.d) Section IV (a), (b), and (c) - Background Questions.

i) Question 1:(1) If you answer “yes” to this question, you must complete Section IV (b) [make additional

copies as necessary] of the application and provide a copy of the arrest report, copies of the disposition or final order(s), and documentation proving all sanctions have been served and satisfied. You must supply this documentation for each occurrence. If you are unable to supply this documentation, a certified statement from the clerk of court for the relevant jurisdiction stating the status of records is required.

(2) If you are still on probation, you must supply a letter from your probation officer, on official letterhead, stating the status of your probation.

ii) Question 2:(1) If you answer “yes” to this question, you must complete Section IV (c) [make additional

copies as necessary] of the application and provide a copy of the judgment or decree. You must also supply documentation proving all sanctions have been served and satisfied, or if not, stating the current status of any proceedings.

iii) Question 3:(1) If you answer “yes” to this question, you must complete Section IV (c) [make additional

copies as necessary] of the application and supply copies of documentation explaining the denial or pending action.

iv) Question 4:(1) If you answer “yes” to this question, you must complete Section IV (c) [make additional

copies as necessary] of the application and supply copies of the order(s) showing the disciplinary action taken against the license, or documentation showing the status of the pending action.

v) Question 5:(1) If you answer “yes” to this question, you must complete Section IV (c) [make additional

copies as necessary] of the application to provide an explanation why you held yourself out or practiced as a CPA within the State of Florida.

e) Section V- Affirmation by Written Declarationi) The applicant must sign the affirmation by written declaration.

5) Authorization for Interstate Exchange of Examination and Licensure Informationa) This form is to be used by any applicant who has previously taken the CPA examination or

held a license in another state.b) This form is essential to the application you are filing with this Board. Before approval of your

application, the Accountancy Board must verify your sitting requirements and/or certificate andlicense status.

DBPR CPA 3 CPA Endorsement Eff. Date: March 2018 Incorporated by Rule 61H1-29.003, F.A.C.

10 of 10 c) Please complete the initial portion of this form and then forward it to the state in which

you previously sat or became licensed.d) The State Board will complete the remaining sections of the form and return it to the Florida

Department of Business and Professional Regulation.e) You are advised to check with each State’s Board before forwarding this form to determine if

there are additional requirements and/or fees charged before such information will be released.

Division of Certified Public Accounting Veloria Kelly, Director

240 NW 76th Drive, Suite A Gainesville, FL 32607-6655

Phone: 850.487.1395 • Fax: 352.333.2508

Jonathan Zachem, Secretary Rick Scott, Governor

LICENSE EFFICIENTLY. REGULATE FAIRLY. WWW.MYFLORIDALICENSE.COM

M E M O R A N D U M

TO: Applicants with degrees from non-accredited institutions

FROM: Florida Board of Accountancy

RE: Foreign Evaluation Service

Transcripts from foreign institutions must be evaluated by one of the evaluation services listed below:

Josef Silny & Associates, Inc. International Education Consultants

7101 SW 102 Avenue Miami, FL 33173

Phone: (305) 273-1616 www.jsilny.com

ACREVS, Inc.1776 Clear Lake Avenue Milpitas, CA 95035-7014

Phone: (408) 719-0015 Toll Free 866-583-4834

www.acrevs.com

International Academic Credential Evaluators, Inc. (IACEI)Post Office Box 2465 Denton, TX 76202-2465

Phone: (940) 383-7498 Fax: 940.382.4874

www.iacei.net

Foreign Academic Credential Evaluators, Inc.P.O. Box 400

Glen Carbon, IL 62034 Phone: (618) 656-5291 www.facsusa.com

Global Services Associates, Inc.409 North Pacific Coast Highway, #393 Redondo Beach, CA 90277

Phone: (310) 828-5709 www.globaleval.org

NASBAInternational Evaluation Services

P.O. Box 198727 Nashville, TN 37219 Toll free: 1-855-465-5382

Local: 1-615-324-1268 Email: nies@nasba.org

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DBPR CPA 32 CPA Work Experience Eff. Date 07/01/2012 Incorporated by Rule: 61H1-27.001(4), F.A.C.

State of Florida Department of Business and Professional Regulation

Board of Accountancy Verification of Work Experience

Form # DBPR CPA 32

VERIFICATION OF WORK EXPERIENCE

INSTRUCTIONS: Please complete and sign the "Applicant Information" section and forward to yourverifying CPA for completion and return to the Department of Business and Professional Regulation.

I hereby authorize my employers (past and present) to release to the Florida Board of Accountancy any information, files and/or records as it may deem necessary in the processing of this verification of work experience.

APPLICANT INFORMATION Last Name First Middle

Street Address or P.O. Box

City State Zip Code (+4 optional)

Date Applicant's Signature

EMPLOYER INFORMATION

Name of employer __________________________________________________________________

Location of office in which applicant was employed ________________________________________

VERIFICATION PERIOD

3. FULL-TIME EMPLOYMENT: Date From: _______/_______/______ To: _______/_______/_______

Number weeks employed ______________________ Applicant still employed: YES NO

Average hours per week employed _____________________________

Total hours employed ________________________________________

4. PART-TIME EMPLOYMENT (Give complete details below. Attach additional statement if necessary.)

Date From: _______/_______/_______ To: _______/_______/_______

Number weeks employed _____________________________________

Average number hours per week employed _______________________

Total hours employed ________________________________________

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DBPR CPA 32 CPA Work Experience Eff. Date 07/01/2012 Incorporated by Rule: 61H1-27.001(4), F.A.C.

INSTRUCTIONS TO VERIFYING CPA: Please complete and forward this Verification of Work Experience form to the Department of Business and Professional Regulation, 2601 Blair Stone Rd,Tallahassee, Florida 32399.

I, the undersigned, state that the applicant named on this certification:

has had one year of work experience which included providing any type of service or advice involving the use of accounting, attest, compilation, management advisory, financial advisory, tax, or consulting skills. This experience was gained through employment in government, industry, academia, or public practice and constituted a substantial part of the applicant’s duties.

has had at least five years of work experience, after licensure as a CPA or Canadian, Mexican, Irish, Australian, New Zealand, or Hong Kong Chartered Accountant, which included providing any type of service or advice involving the use of accounting, attest, compilation, management advisory, financial advisory, tax, or consulting skills. This experience was gained through employment in government, industry, academia, or public practice and constituted a substantial part of the applicant’s duties.

I state that these statements are true and correct and recognize that providing false information may result in disciplinary action against my license or criminal penalties pursuant to sections 455.2275 and 837.06, Florida Statutes.

Verifying CPA’s Name ____________________________________________________________

CPA License Number ________________ Date Original License to Practice Issued __________

State in which certified ____________ Expiration Date of License _____________________

________________ _______________________________________________________ DATE SIGNATURE OF VERIFYING CPA

Is there any additional information concerning the good moral character or technical fitness of the employee relative to his/her practice of public accounting that you feel the Board should be informed of? ____ Yes ____ No

(If "Yes", please attach written explanation.) Good moral character means a "personal history of honesty, fairness, and respect for the rights of others and the laws of this state and nation."

Page 1 of 2

DBPR CPA 41 CPA: CPE REPORTING FORM EFFECTIVE DATE: JANUARY 2016 INCORPORATED BY RULE 61H1-33.003, F.A.C.

Participant

AA TB Ethics Beh.

Instructor

AA TB Ethics Beh.

Total

AA TB Ethics Beh.

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FLORIDA BOARD OF ACCOUNTANCY CONTINUING PROFESSIONAL EDUCATION

REPORTING FORM

NAME: LICENSE NUMBER: Credit Hours Claimed

(Half-hour increments allowed)

Name of Provider

(Check box is Self-Study) Completion Date

(MM/DD/YYYY) Name of Course or

Program

I certify that the above information is true and correct and that the reported courses directly relate to enhancing my professional knowledge and competence. I have properly identified all sponsored courses with the correct provider name. I understand that any or all credit is subject to review.

TOTAL OF ALL HOURS:

FLORIDA ETHICS COURSE

COURSE NAME DATE OF COMPLETION

COURSE NAME DATE OF COMPLETION

SIGNATURE DATE

Page 2 of 2

DBPR CPA 41 CPA: CPE REPORTING FORM EFFECTIVE DATE: JANUARY 2016 INCORPORATED BY RULE 61H1-33.003, F.A.C.

INSTRUCTIONS FOR COMPLETING THIS FORM

1. Courses must be listed in chronological order directly on the form to make it complete. Original signature and date is required. Licensees should retain documentation evidencing coursecompletion for at least two years in the event they are selected for the CPE audit. NOTE: IF COMPLETING THIS FORM IN RESPONSE TO CPE AUDIT PLEASE INCLUDE THE ETHICSCOURSE NUMBER AND DATE COMPLETED IN THE ETHICS HIGHLIGHT BOX.

2. List the hours claimed in the appropriate column. Half-hour increments are allowed. Fractional hours must be rounded down to the nearest half-hour. Any fractional hour reported that is lessthan one half-hour will be removed. Total all columns and indicate the total of all hours from all categories in the box at bottom.

3. Please indicate self-study or correspondence course(s) by writing the provider’s name and marking the box beside the provider’s name. Please also note all self-study continuing professionaleducation courses qualifying for accounting and/or auditing and technical business credit must be taken from providers approved by NASBA’s Quality Assurance Service (QAS) program. QASapproved providers and courses can be found on NASBA’s website at http://www.nasba.org or by telephone at 615.880.4200.

4. Credit can be claimed for two types of activity: (1) hours earned as a participant and (2) hours earned as an instructor or lecturer. If you are reporting hours of instruction, you may claim doublecredit for the first presentation of the course, single credit for the second presentation of the same course and no credit thereafter except for new content (See Rule 61H1- 33.003(4)(b)3 F.A.C.

5. Continued Professional Education Hours required for:

a. Renewals: Pursuant to Rule 61H1-33.003(1)(a) F.A.C. in any given reestablishment period, each current/active Florida certified public accountant must have completed at any time ortimes during the two-year period, at least 80 hours of educational instruction or training in public accounting subjects or courses of study, as defined hereinafter, of which at least 20hours must have been in accounting-related and/or auditing-related subjects and of which no more than 20 hours may be in behavioral subjects and at least 4 hours shall be in FloridaBoard-approved ethics. Rule 61H1-33.003(1)(b) F.A.C. Florida certified public accountants who do not meet the requirements by June 30th will be granted an automatic extension untilSeptember 15th provided the Florida certified public accountant completes an additional 8 hours in Accounting and Auditing subjects. An automatic extension will be granted untilDecember 31st provided the Florida certified public accountant completes an additional 16 hours in Accounting and Auditing subjects.

b. Endorsement Applicants: Pursuant to Rule 61H1-29.003(1) F.A.C. any applicant seeking licensure by endorsement under Section 473.308(7)(a), F.S., and having not been licensedin another state, shall have completed continuing education meeting the requirements of Rule 61H1-33.003, F.A.C., for the two (2) years immediately preceding the filing of theapplication. Rule 61H1-29.003(2) F.A.C. any applicant seeking licensure by endorsement under s. 473.308(7) (b), F.S., and having been licensed in another state, shall have completed whatever continuing professional education is required by that state to maintain an active license to practice public accounting in that state, so long as such requirements are equivalentto those required by Rule 61H1-33.003 F.A.C., for the two (2) years immediately preceding the filing of the application.

c. Reactivation Applicants: Pursuant to Rule 61H1-33.006(2) each such application shall demonstrate successful completion of the required number of continuing professionaleducation hours. (a) Licensees who have been inactive or delinquent for one reporting period following their most recent current/active license, shall satisfy the requirements of theirmost recent biennium while active plus 40 additional CPE hours in the following manner: 120 total hours to include at least 20 hours in accounting/auditing subjects, 4 hours in board approved ethics, and no more than 20 hours in behavioral subjects. (b) Licensees who have been inactive for no more than two reporting periods since maintaining a current/activelicense, shall satisfy the requirements of their most recent biennium plus 120 additional CPE hours in the following manner: 200 total hours to include at least 30 hours inaccounting/auditing subjects, 4 hours in board approved ethics, and no more than 20 hours in behavioral subjects. (c) Licensees who have been inactive for three or more reportingperiods since maintaining a current/active license, shall satisfy the requirements of their most recent biennium plus 200 additional CPE hours in the following manner: 280 total hoursto include at least 40 hours in accounting/auditing subjects, 4 hours in board approved ethics, and no more than 20 hours in behavioral subjects. 61H1-33.006(3) Florida certified publicaccountants who have been inactive for two or more reporting periods since maintaining a current/active license must complete at least 60% of the necessary hours in the 24 monthsimmediately preceding the date of the application for reactivation and the remaining 40% may have been completed no more than 48 months immediately preceding the date of theapplication for reactivation.

6. CPE Guidelines: The Accounting and Auditing category include courses on financial reporting, financial auditing, the related pronouncements, and accounting for specialized industries. Thetechnical business category includes courses on taxation, MAS, and general business subjects. The behavioral category includes courses on oral and written communication, socialenvironment of business, practice administration, management, and marketing. The ethics courses are approved by the Florida Board of Accountancy. For a list of approved ethics coursesgo to http://www.myfloridalicense.com/dbpr/cpa/CPE.html. Contact 850.921.8582 with questions regarding approved courses.

State of Florida Department of Business and Professional Regulation

Board of Accountancy Authorization for Interstate Exchange of Examination and Licensure Information

Form # DBPR CPA 5012-1

If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at (850) 487-1395.

APPLICANT INFORMATION This form is essential to the application you are filing with this Board. Before approval of your application, the Accountancy Board must verify your sitting requirements and/or certificate and license status. Please complete the initial portion of this form and then forward it to the state in which you previously sat or became licensed. That Board, in turn, will complete the remainder of this form (Sections A-D) and return it to this agency. (You are advised to check with the Board before forwarding this form to determine if there are additional requirements and/or fees charged before such information will be released.) This form is must be filled out by all states in which you previously sat or became licensed. TO BE COMPLETED BY THE APPLICANT (Please type or print legibly): Last Name First Middle Title Suffix

Address Certificate Number (if applicable)

City State Zip Code

Phone Date of Birth Social Security Number*

*Under the Federal Privacy Act, disclosure of Soc. Sec. Numbers is voluntary unless specifically required byFederal status. In this instance, social security numbers are mandatory pursuant to Title 42 United States Code, Section 653 & 654; and sections 445.203(9), 409.2577, &409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants & licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional & occupational license applications & will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193,Sec. 317.

I hereby request and authorize the ____________________________________ Board of Accountancy to provide any and all pertinent information requested in this form to the Board of Accountancy in the state of Florida to complete an application filed with that agency. I agree that the state Board may confirm the grades issued to me by the Advisory Grading Services of the American Institute of Certified Public Accountants.

____________________________________________________________________ _____________/_________________/______________ Applicant Signature Date Signed

SECTIONS A THROUGH D ARE TO BE COMPLETED BY THE BOARD OF ACCOUNTANCY ONLY

SECTION A: VERIFICATION OF EXAMINATION CREDITS: The following are grades awarded on the Uniform CPA Examination(s) for the applicant above, as reported by the AICPA Advisory Grading Service. Please use Section D of this form to explain if any of the grades were changed; if an exam other than the Uniform CPA Exam was used; or, if there is any reason why the grades should not be accepted. If separate sheet is attached, please affix official signature and board seal.

Date of Examination Candidate I.D. Number

AUDIT LPR (Business Law)

FARE (Theory)

ARE (practice)

1. Was the applicant ever denied admission to the Exam? Yes No (If yes, please useSection D of this form to explain.) 2. Date applicant was first approved to sit for the exam: ________________________________.3. If the applicant has not completed the CPA Exam, are there any restrictions preventing him/herfrom sitting in your state? Yes No 4. If the candidate has not passed all parts of the CPA Exam, indicate above the expiration dateof those parts that have been passed and for which credit has been given. 5. Would the applicant be denied admission to any future exams? Yes No

SECTION B: CERTIFICATE/LICENSURE (Permit) STATUS Certificate As A Certified Public Accountant: 1. The applicant was granted an original/reciprocal (mark out one), CPA Certificate number

____________ issued ______/______/______ which is in good standing unless otherwisenoted in Section D of this form.License/Permit to Practice Public Accounting: (If licensing is the responsibility of anotheragency, please forward and request completion of applicable section.)

2. Yes No This state is a two-tier state.3. Yes No This license/permit from this board is in good standing.4. This license/permit expires on _____________________.5. Yes No The applicant is currently licensed to engage in the practice of publicaccounting. 6. Yes No Has there ever been any disciplinary action instituted against the applicant? If

yes, please explain in Section D.7. If the applicant does not hold a license/permit from your board, please indicate the

requirements to be met for issuance of reinstatement:License/Permit not required___________________________________________________________Pay appropriate fees and/or post bond__________________________________________________Complete continuing professional education requirements___________________________________Other (please specify):_______________________________________________________________

SECTION C: ADDITIONAL INFORMATION REQUESTED

SECTION D: EXCEPTIONS NOTED OR EXPLANATIONS FOR INFORMATION PROVIDED (Official Seal and Signature must be affixed to attached sheets if needed to respond to this inquiry)

The information provided herein is correct to the best of my knowledge.

OFFICIAL _____________________________________________ BOARD Board/Agency SEAL _____________________________________________

Official Signature _____________________________________________

Title Date

Please mail the completed form to:

State of Florida Department of Business and Professional Regulation

Board of Accountancy 2601 Blair Stone Rd

Tallahassee, FL 32399